PRESENTED BY: DR.SHILPA PRAJAPATI (1st YEAR MPT)

An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in term of such damage.

-International Association For the Study of pain

NEUROPATHICNOCICEPTIVE

Deafferentation Sympathetic Maintained

Peripheral

Somatic• bones, joints• connective tissues• muscles

Visceral• Organs –

heart, liver, pancreas, gut, etc.

• Aching, often constant• May be dull or sharp• Often worse with movement• Well localized

Eg– Bone & soft tissue– chest wall

Somatic pain and visceral pain are actually two very different types of pain. Somatic pain comes from the skin and deep tissues, while visceral pain comes from the internal organs. Both somatic pain and visceral pain are detected the same way: Nociceptors, or pain-detecting nerves, send an impulse from the painful site up through the spinal cord and to the brain for interpretation and reaction. This is called nociceptive pain, and differs from neuropathic pain, which is caused by nerve damage. Though they are detected in similar ways, somatic pain and visceral pain do not feel the same

How Somatic Pain Feels Somatic pain is generally described as

musculoskeletal pain. Because many nerves supply the muscles, bones and other soft tissues, somatic pain is usually easier to locate than visceral pain. It also tends to be more intense. Some chronic pain conditions caused by somatic pain include:

• Constant or crampy• Aching• Poorly localized• Referred

Eg– CA pancreas– Liver capsule distension– Bowel obstruction

How Visceral Pain Feels Visceral pain is internal pain. It comes

from the organs or the blood vessels, which are not as extensively innervated, or supplied by, sensory nerves. Unlike somatic pain, visceral pain may feel dull and vague, and may be harder to pinpoint. Some common types of visceral pain include:

COMPONENT DESCRIPTORS EXAMPLES

Steady, Dysesthetic

• Burning, Tingling

• Constant, Aching

• Squeezing, Itching

• Allodynia

• Hypersthesia

• Diabetic neuropathy

• Post-herpetic neuropathy

Paroxysmal, Neuralgic

• Stabbing

• Shock-like, electric

• Shooting

• Lancinating

• trigeminal neuralgia

• may be a component of any neuropathic pain

MECHANORECEPTORS -Meissner’s Corpuscles (light touch) - Pacinian corpuscles (deep pressure) - merkel's corpuscles (deep pressure) THERMORECEPTOR -krause's end bulbs (decrease

temperature, touch ) -ruffini corpuscles( in the skin)

PROPRIOCEPTOR -muscle spindle , golgi tendon NOCICEPTOR

ACUTE: onset is well defined, response to tissue injury, responds to pain treatment, associated with anxiety, affects the individual

CHRONIC PAIN:Onset is ill defined,response to change in nervous system, less response to medication,associated with depression, involves social network

MELZACK & WALL,1965- Substentia Gelatinosa(SG) in dorsal horn of spinal cord acts as a "gate"- only allows one type of impulses to connect with the SON

Transmission Cell(T-cell)- distal end of the SON

If A-beta neurons are stimulated- SG is activated which closes the gate to A-delta & c neurons

If B-delta and C neurons are stimulated- SG is blocked which closes the gate to A-beta neurons

Gate - located in the dorsal horn of the spinal cord

Smaller, slower nerve carry pain impulses Larger, faster nerve fibers carry other sensations

Impulses from faster fibers arriving at gate 1st inhibit pain impulses (acupuncture/pressure, cold, heat, chem. skin irritation).Brain

Pain

Heat, Cold, Mechanical

Gate (T cells/ SG)

Descending neurons are activated by: stimulation of A-delta & C neurons, cognitive processes, anxiety, depression, previous experiences, expectations which Cause release of enkephalins (PAG).

Enkephalin interneuron in area of the SG blocks A-delta & C neurons

Least understood of all the theories

Stimulation of A-delta & C fibers causes release of B-endorphins from the PAG

Mechanism of action – similar to enkephalins to block ascending nerve impulses

Examples: TENS (low freq. & long pulse duration)

Unlike specificity theory, pattern theory suggests that there are no separate systems for receiving pain, but instead the nerves are shared with other senses like touch.

The most important feature of pain is the pattern of activity in the nervous system. So, too much stimulation (eg too much touch) will cause pain.

Reduce pain!

Control acute pain!

Improve healing process

Reduce inflammation and edema

Decrease spasm and improve muscle contraction

Use to control pain

Muscle spasm decrease as result of decrease activity in gamma motor efferent,decrease excitability of muscle spindle and increase activity of Golgi tendon organs

Moist heat packs and paraffin are examples of therapeutic conductive heating

Therapeutic convective heating take place during hydrotherapy

Therapeutic radiant is supplied infrared

Cold therapy is the best modality for acute inflammatory reactions like: Acute inflammation of the bursa (bursitis) Epicondylitis (tennis elbow, golfer’s elbow) Acute trauma

Cold therapy reduce:Muscle spasm secondary to:Underlying joint and skeletal pathologyNerve root irritationEdema, hyperemia (excess blood in tissue)

and painDue to its vasoconstrictive (constriction of

blood vessels) effect

A local decrease in tissue temperature Reduction in metabolism Vasoconstriction (initially) Reduce blood flow (initially), Reduce muscle excitability, muscle spindle

activity Reduce nerve conduction velocity Reduction in lymphatic and venous drainage Reduce Decrease formation and

accumulation of edema Anesthesia

After some minutes the vasoconstriction may give way to a marked vasodilatation which it self may last some 15minute before being replaced by another episode of vasoconstriction

This alteration is called the “Lewis hunting reaction” (Lewis, 1930), in the sense that the vessels hunts about its mean position

Electromagnetic waves that produce heat

Frequency of 27.12 MHz and wavelength > 11 m.

Use inmuscle spasm- pain relief,

Delayed healing

Chronic inflammation- increase blood circulation

Fibrosis- increases extensibility of fibrous tissue

Principle effect is production of heat in the tissues ↓ rise temperature of that part ↓ Relaxation of muscle and increase the efficiency of their action ↓ Increase blood supply ensuring the optimum condition for the muscle contraction.

parameters Chronic condition Acute condition

Intensity comfortable warmth Below sensation of warmth

Duration 20 minutes 10 minutes

Frequency Daily Twice a day

Electromagnetic radiation

Frequency 2450 MHz and wavelength 12.245 cm

Relief pain- in traumatic and rheumatic condition

Muscle spasm Inflammation- increase blood supply and

resorption of edema Delayed healing- promote healing

Principle effect is production of heat in the tissues

↓ rise temperature of that part ↓ Relaxation of muscle and increase the

efficiency of their action ↓ Increase blood supply ensuring the optimum condition for the muscle contraction.

To produce deep tissue heat by molecular friction

It helps to: Decrease the joint pain

Prepare the joint for mobilization/manipulation

It can break adhesions and calcification (e.g. calcific bursitis)

Combined with deep tissue massage (trigger point therapy) it is effective for treatment of myofascitis

It is impossible to treat C or A fiber selectively, ultrasound provides both pain relief and relief from muscle spasm

Sounding of C fibers produce pain relief whereas sounding of large diameter fibers bring relief of spasm by changing gamma fiber activity, making muscle fiber less sensitive to stretch.

Transcutaneous Electrical Nerve stimulation TYPES

High tens or conventional tens (high freq:100-150Hz, law intensity:12-30mamp)

Low tens or acupuncture tens (high intensity:300mamp, law freq:1-5Hz)

Burst tens(50-150Hz)

Brief tens (high freq:100Hz, law intensity:20-50mamp)Modulated tens

Tens selectively stimulates the low-threshold, large-diameter A-beta fibers

It resulting in presynaptic inhibition within the dorsal horns

Tens delivered at low rate is thought to facilitate elevation of the level of endogenous opiates in the CNS

Pulse shape Rectangular type impulses

Pulse width 100 microsecond, generally 50 microsec- 300 microsec

Inensity 0 – 60 milliamp, satisfactory intensity till tingling sensation

Frequency range effect

1 – 250 pulse per second decrease pain

50 – 100 pps sensory level (high level)

2 – 3 pps Motor level (low level)

2 pps Increase in the pain threshold

short frequency therapeutic current

TypesPlainSurged faradic

Its use Muscle contraction that is inhibited by

painPumping action which result in increase

venous and lymphatic returns

Chemical ions are driven through the skin by small electrical current

Ionizable compounds are placed on the skin under the electrode, which when polarized by direct(galvanic) current, repels the ion of like charge into the tissue

Ions are known to be effective analgesics:XylocainHydrocortisone Manesium Iodinesalicylate

Light amplification by stimulated emission of radiation

A low intensity laser therapy is used

It resolve inflammation and infection Reduce pain Increase speed, quality and strength of tissue

repair

TYPES: Rubby laser, Helium-neon laser, Diod laser

Laser―photons

↓

Visible red light absorbed in the mitochondria,

infrared light absorbed at the cell membrane

↓

Single oxygen production

↓

Formation of proton gradients across cell membrane and

across membrane of mitochondria

↓

Physiological changes

Change in cell membrane permeability

Increase ATP levels-DNA production

Influences cell metabolism

↓

Activation of regulatory process

1) Power Density (W/cm2) = Laser Output Power (W)/Beam area (cm2)

2) Beam Area (cm2) = Diameter(cm)2 x 0.7854

3) Energy (Joules)=Laser Output Power (Watts) x Time(Sec)

4) Energy Density (Joule/cm2)=Laser Output Power (Watts) x Time(Sec)/Beam Area (cm2)

5) Treatment Time (Seconds)=Energy Density (Joules/cm2)/Output Power Density (W/cm2)

THANK YOU!